In 2008, Korea spent 6.5% of its GDP on health care (Organisation for Economic Co-operation and Development [OECD] 2010). Of the total health care budget, government sources and social insurance accounted for 55.5%, while the remaining 44.5% had to be paid privately (Jeong 2010). Though the health care spending of Korea, as a share of GDP, is the third lowest among the OECD nations, its growth rate was the fastest over the past decade due to the rapid aging of the population and the expanding of NHI benefits (Jones 2010).
Health care services are delivered mainly by the private sector; 90% of physicians work in private clinics and hospitals, and 96% of hospitals and clinics are privately owned, which accounts for 90% of beds (Jones 2010). Providers are reimbursed mainly by a fee-for-service scheme supplemented by a diagnosis-related group (DRG) in some inpatient care. There is no formal gate-keeper, and clinics and hospitals perform similar functions, resulting in a limited role of primary care, and competition rather than coordination among physicians in clinics and hospitals is prevalent (Kwon 2009).
Current programs for care coordination
There are three nation-wide care coordination programs for people with chronic conditions in the public sector. One is for NHIC’s beneficiaries with targeted chronic diseases, another is for MA’s beneficiaries who heavily use medical services, and the third is for residents who voluntarily enrolled in local public community health centers (PCHCs). Through community-based intervention, all of these programs are trying to achieve common goals of reducing cost, ensuring quality services, and improving clients’ health outcomes.
Case management of NHIC
When NHIC experienced a financial deficit in 1997, various efforts aiming at fiscal sustainability and cost containment were made. In 2002, NHIC introduced the Case Management Program for Chronic Diseases (CMPCD) as a demonstration project from August 2002 to December 2003. During that period, 15 teams composed of two case managers were deployed to 15 local NHIC offices with support from professionals in medicine, nursing, and social welfare from 13 local universities. By the end of the CMPCD, target population priority, an education program for the CMPCD’s case managers, five disease-specific needs assessment tools, care plans based on comprehensive need assessment, a case management process, and an information system supporting the case managers’ routine work had been developed with active participation of the case managers (Kim et al. 2008).
Target population
At first, CMPCD targeted five major chronic diseases: essential hypertension (HTN), type 2 diabetes mellitus (type 2 DM), congestive heart failure (CHF), stroke, and children’s asthma based on the burden of each disease and the availability of effective intervention. Using NHIC’s nationwide claim data, NHIC identified those people with one of these five target diseases, and classified them into an under-utilizing or an over-utilizing group, according to their total number of consultations and treatment days.
However, there have been some unexpected problems with identifying and selecting two target populations. Clients with CHF were rare and it was difficult to meet them within the community. For children’s asthma, the disease code in the claims data was frequently found to be incorrect. As a result, CHF and children’s asthma were excluded from the target diseases to increase the efficiency of the CMPCD since 2004. Arthritis was newly included as another target disease in 2007 (Kim et al. 2008).
In 2010, NHIC has reformed to link its biennial Health Screening Program (HSP) and CMPCD. The CMPCD is now targeting those people who are newly identified to have HTN or type 2 DM through HSP within the past six months. The NHIC is expecting it can provide CMPCD services for about 50,000 new clients through NHIC’s 494 lay workers each year.
Case manager
In 2002, the NHIC recruited 31 registered nurses (RNs) with at least three years of clinical experience in clinics or hospitals as case managers and had developed education and training programs for their own case managers (Table 29.2). As the Korean government has been trying to reduce the NHIC’s workforce to lower its operating costs since 2002, the NHIC has not been able to recruit additional RNs required when the CMPCD expanded to a nationwide service in 2004. The NHIC then decided to use lay workers (staffs of the NHIC) for the CMPCD. Before the lay workers started their new job as a case manager, they received a one-week education program and a month of field training supervised by a skilled RN case manager.
Table 29.2 Training Course for the NHIC’s Certified Case Managers
To improve the expertise of the case manager, the NHIC introduced a two-level certificate for its own case managers and has been providing training courses for the first grade (advanced level) and the second grade (skilled level) case managers since 2006. The two certification courses have been operated by the NHIC and commissioned to an external institute, the Nursing College of Seoul National University. The training course of the second grade is a three-week, 95-hour course covering 40 subjects, and the first grade is a two-week, 56-hour course covering 20 subjects that is required to successfully implement and manage the CMPCD (Shin 2009).
Process
Every six months, case managers of a local office receive a list of the target population residing in each designated area and send a letter to potential clients introducing the CMPCD and informing them how to utilize the service. After they have received consent from the clients, case managers provide a 12-week service consisting of at least four home-visits and two telephone calls. The first home-visit is for needs assessment and the last one is for identifying the effectiveness of the services. Telephone calls are made to monitor and support clients during the intervention phase.
Through a face-to-face interview, case managers assess the client’s needs using a questionnaire, ‘needs assessment tool’ developed by the NHIC. The questionnaire covers seven categories: socioeconomic information, medical information, utilization of health care services, knowledge about their specific disease, self-management, health-related behavior, and social support. An individualized care plan and goals of each action plan are developed based on the data collected during the first visit and entered into the NHIC’s information system (see Table 29.3).
Table 29.3 Process of NHIC’s Case Management Program
Source: Modified from So (2008)
| Process | Activities |
| Phase 1 Selecting clients | Select a client based on preset criteria Send an information letter Make an appointment by telephone |
| Phase 2 Assessing needs and planning interventions | 1st visit Undertake needs assessment using the needs assessment tool Select problems by preset standard Establish care plans with client |
| Phase 3 Doing interventions | 2nd visit-1st phone call 3rd visit-2nd phone call Provide interventions concerning the problem list |
| Phase 4 Evaluating the effectiveness of Case Management services | 4th visit Identify changes of the client using the same needs assessment tool Evaluate the achievement of goals of services |
With an individualized comprehensive care plan, case managers can identify diverse needs and concentrate their efforts on higher priority needs. However, the care management program has a limited role because there is no obligation or financial incentive for physicians to cooperate with the case manager and the NHIC’s CMPCD does not include any kind of formal cooperation with physicians who provide care for the clients.
Recently, with the change of the target population, focusing on the newly identified patients with HTN or type 2 DM and patients with low compliance, there has been efforts made to modify the intensity and method of interventions depending on the level of motivation of the clients.
Results
A total of 171,919 clients utilized the CMPCD service through 2008 and clients’ satisfaction was very high (84.9 on a 100 point scale). There have been many studies reporting the short-term effect of the NHIC’s CMPCD, including the improvement of blood pressure or blood sugar control, daily life practices, physical activities, medication adherence, functional status, and caregiver burden (Shin et al. 2003; Kim et al. 2004; So et al. 2008). However, there is no evidence supporting the long-term effects of the services and their impact on cost containment has not been identified.
Case management of medical aid
In May 2003, the Case Management for the Medical Aid Beneficiaries (CMMAB) was introduced by MHW in 28 districts of Korea as a demonstration project to support self-management and health service utilization of clients and to reduce costs. Through a gradual expansion, in 2006 all 232 districts in Korea provided CMMAB to those people who need help for effective self-care and a guide to complex health care services, and have a tendency to use medical services heavily.
The Medical Aid program is composed of individuals with higher needs for health care than NHIC. For example, the ratio of the elderly in MA is approximately four times that of the NHIC, and the registered disabled and people with a rare and incurable disease, like chronic renal failure, are much more concentrated in MA.
Unlike the NHIC’s CMPCD which focuses on a specific disease, CMMAB focuses on an individual, and most have multiple chronic conditions. In addition, case managers may limit access to medical service for clients if they receive permission from the local Medical Aid committee, based on the Medical Aid Act. If a client receives this penalty, the MA benefit will be stopped until the end of the year, and the client must pay all of the cost without the support of the MA benefit.
The Medical Aid Case Management Center (MACMC), supervised by the MHW, was established in 2007. Its main functions are planning and evaluating CMMAB, providing a training program and technical support for case managers and updating practice guidelines.
Target population
The CMMAB targeted those people newly entitled to MA benefits and those who are more likely to heavily use medical services; people whose medication is prescribed beyond 365 days a year for the same disease, who have a tendency to visit two or more clinics (or hospitals) frequently for the same disease, and those who are on long-term inpatient care for more than 31 days. In 2010, CMMAB added hospitals and long-term care facilities as another subject of CMMAB intervention where long-term hospitalizations are occurring more frequently than others.
The MA target population, and the list of clients, is identified using claims data from the HIRA, which is updated periodically. Of the 247,878 CMMAB recipients in 2009, 51,747 (20.6%) were re-enrolled clients who had received the CMMAB service the previous year (MACMC 2010).
Case manager
At first, the MHW recruited 28 case managers from licensed RNs and social workers, but has narrowed employment criteria only to RNs with three or more years of clinical experience.
With stepwise expansion of the CMMAB, the number of MA case managers also increased. At the end of 2009, there were 463 case managers, deployed in the local government at a ratio of one case manager per 2,500 MA beneficiaries. In 2010, a skilled case manager has been placed in the regional administrative authority to supervise and support CMMAB within local areas. A case manager is supposed to provide services to 320 clients per year (MHW 2010b).
The MACMC provides two three-day training courses several times a year for the case managers. One is for the new case manager, and the other is for the experienced. Case managers must complete at least one course per year. In addition, there are other intermittent education programs operated at the regional or local level. Currently, there is no certification or license program for the MA case manager.
Process
Based on the claims data, the HIRA identifies and selects the list of clients for each local area and provides it to local case managers on a quarterly schedule. Priority is given to newly enrolled MA beneficiaries, heavy users of outpatient services, and patients on long-term hospitalization.
According to the client’s previous pattern of service utilization, case managers classify their clients into four subgroups: a high-risk group, an unmet-need group, a temporary-management group, and a newly enrolled group. The high-risk group is in danger of abusing or misusing medications and medical services, as they are likely to visit medical institutions more frequently than other clients and get duplicated prescriptions. The unmet-need group is likely to under-use medical services given the client’s needs of diagnosed disease. The temporary-management group consists of clients who are not identified by HIRA but only by a case manager. The newly enrolled group is composed of the people who enrolled in MA for the first time and need basic information about MA.
The intensity of provided services depends on group assignment. More than two home-visits and four phone calls are provided for the high-risk group, more than one home-visit and two phone calls for the unmet-need group, one or two home-visits or phone calls for the temporary-management group, and one or two phone calls and a mailing of informational pamphlets for the newly enrolled group.
Needs assessment information is collected in a face-to-face interview during home-visits using the structured needs assessment tool and computerized information already available to the local authorities, the NHIC, and the HIRA. The needs assessment tool, developed and periodically being revised by the MACMC, covers seven categories: demographic information, knowledge about MA, pattern and quantity of medical service utilization, health status, self-care, social support, and residential environment.
Based on the comprehensive needs assessment, a care plan for each client and goals for action plans are made. Before they terminate services, case managers evaluate the services by re-measuring the client’s needs using the same need assessment tool.
Results
In 2009, of the total 1.7 million MA beneficiaries, 247,878 clients (14.7%) were provided services by 463 case managers. Approximately 32% of beneficiaries receiving services were initially classified in the high-risk group as well as the temporary-management group, 19% were in the newly enrolled group and 10% were in the unmet-need group. Satisfaction with the services provided was high (80.4 on a 100 point scale), and it is estimated that approximately $23 million was saved due to the nation-wide CMMAB (MACMC 2010). The improvement of health related quality of life, self-care, and changes in service utilization were significantly greater in the high-risk group than the unmet-need group (Ahn 2010).
Case management of community health center
The Individual Home Visiting Health Care (IHVHC) is the representative service of Public Community Health Centers (PCHC) and it is provided by 253 PCHCs nationwide. Its prototype began in 1990, but a full-scale IHVHS with a greater expansion of workforce and a more systematic approach began in 2007.
Target population
The IHVHC provides services for low-income populations with priority given to pregnant women, infants, immigrants, the disabled, and the elderly. In 2009, of 1.5 million clients, 930,403 (77.7%) had one or more chronic conditions in need of care. Unlike CMPCD or CMMAB, the clients are identified and enrolled by self-registration, referral from CMPCD or CMMAB, or by lay people.
Case manager
A multidisciplinary team provides its services based on an individual care plan. There are 2,700 IHVHC staff and RN case managers that play a core role with other PCHC staff, including physical therapists, dietitians, dental hygienists, and social workers. There are two training courses for RN case managers. One is for new case managers and the other is for the already skilled.
The RN case managers assess the client’s needs and create a care plan using a comprehensive needs assessment tool and a computerized information system. They can provide home nursing services, which is not possible in the CMPCD or the CMMAB.
Process
Case managers implement needs assessment during the initial home visit. Based on the results, clients are classified into three subgroups: an intensive care group, a routine care group, and a well-controlled group.
According to an individual care and action plan, case managers provide or coordinate services for a year. They adjust the number of their home visits depending on group classification: for the intensive care group, at least once a month; for the routine care group, at least once every three months; and for the well-controlled group, at least once a year. Clients may use the IHVHC service up to two years if they are in need of the services. The PCHC’s information system is an integral tool that assists case managers in doing their job and keeping up with vital information on their clients.
Results
A total of 1.5 million clients used the IHVHC services in 2009; routine group clients accounted for 76.7% of the service use; well-controlled clients 22.3%, and the intensive group 1%. Almost all clients (97.1%) responded that they were satisfied with the IHVHS services (MHW 2010a). According to a recent study, the benefit-cost ratio of IHVHS was 9.16 and the benefit of arthritis management was the largest among disease management programs (Kim et al. 2010).
Summary and future challenges
Financial instability of the health security system, and the quickly aging population with the epidemiologic transition to chronic diseases have triggered the development of individualized intensive interventions such as CMPCD, CMMAB, and IHVHC. Since 2002, education programs and training courses for case managers have developed, and knowledge, information, and an evidence-base of case management has accumulated. Though there is some evidence that current programs are effective or efficient, still there are questions to be answered. For example, the effectiveness or efficiency of current programs has to be confirmed by well-designed studies. Furthermore, the education programs or training courses for case managers should be evaluated in terms of how they meet their needs. Involving primary care physicians who could significantly change or have an effect on clients’ knowledge, attitude, behavior, and medication is another critical issue to be examined.
As Korea has been experiencing a rapid aging of the population, people with chronic conditions are increasing at a rapid pace. It is difficult to expect optimized care within a fragmented and complex health care delivery system. Coordination of care is helpful and effective for these people with chronic diseases, especially those with multiple chronic conditions that need continuous attention and care. And it may provide opportunities to strengthen primary care and improve efficiency of our fragmented health system. With efforts to reform the current health care delivery system, care coordination could be a means of ensuring good care and reducing costs.
References
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